Neurosurgeons as Neurointensivists

harbGuest post from Robert E. Harbaugh, MD, FAANS
AANS Past President
SNS President
Director, Institute of the Neurosciences
Distinguished Professor and Chair, Department of Neurosurgery
Professor, Department of Engineering Science & Mechanics
The Pennsylvania State University
Milton S. Hershey Medical Center
Hershey, PA

Neurocritical care is part of the continuum of neurosurgical care and neurosurgeons are trained to care for their patients in a critical care setting. Despite this, neurosurgeons in the United States were at risk of losing their role as neurointensivists. This report will review the accomplishments of organized neurosurgery regarding certification of neurosurgeons as neurointensivists.

The American Board of Neurological Surgery (ABNS) Certification
The American Board of Neurological Surgery (ABNS) defines the scope of neurosurgical practice; sets the standards of neurosurgical education, training and practice; defines the requirements for training; develops and administers a primary examination; evaluates the credentials of candidates for certification, including professional practice; develops and administers an oral examination; issues board certification certificates; and defines requirements for maintenance of certification (MOC) in neurological surgery.

Clearly, the evaluation and management of neurosurgical patients in critical care settings is explicitly articulated as being within the scope of neurosurgical practice by the ABNS. As such, ABNS certification alone is sufficient for neurosurgeons to care for their own patients in a critical care setting. However, additional training and/or certification in neurocritical care, for those neurosurgeons who make neurocritical care a major part of their practice, can be obtained as described below.

SNSThe ABNS/SNS CAST Process for Certifying Neurosurgeons as Neurointensivists
The Society of Neurological Surgeons’ (SNS) Committee on Advanced Subspecialty Training (formerly the Committee on Accreditation of Subspecialty Training), or CAST, was formed in 2001 to offer accreditation of subspecialty training programs in neurosurgery. Training standards were established by the subspecialties through the Joint Sections of the American Association of Neurological Surgeons and Congress of Neurological Surgeons, with specifications for facilities, faculty, affiliated services, patient care, and procedural volumes. Since its inception, the CAST process has been based on the principle that subspecialty recognition should be based on proficiency, which may occur during or after residency.

In its effort to certify and standardize subspecialty training in neurological surgery, the SNS CAST is working closely with the ABNS to make sure that there is agreement across our neurosurgical organizations. Until recently, CAST accredited subspecialty training programs did not issue certificates to individuals. During his tenure as SNS President, Ralph G. Dacey, Jr., MD, FAANS, created the CAST Task Force to consider expanding the role of CAST to include subspecialty certification of neurosurgeons. Other members of the task force included:  Arthur L. Day, MD, FAANS; Stephen L. Giannotta, MD, FAANS; Robert E. Harbaugh, MD, FAANS; and Volker K.H. Sonntag, MD, FAANS. Neurocritical care was the first subspecialty that the CAST Task Force was neurocritical care.

The SNS Executive Council approved CAST Task Force recommendations for the program requirements for CAST accreditation of neurocritical care training programs, as well as the criteria for CAST certification of neurosurgeons and other specialists with subspecialty expertise in neurocritical care. These requirements include a “Practice Track” pathway for neurosurgeons and others who had already completed subspecialty training in neurocritical care prior to the availability of CAST accredited training programs, or who already have a subspecialty practice in neurocritical care. The requirements for accreditation of programs and certification of individuals, including the criteria for both post-graduate and enfolded fellowships, can be found on the SNS website. CAST is working with the ABNS to grant certificates to neurosurgeons who have completed a CAST accredited fellowship. The group is also collaborating with the Accreditation Council for Graduate Medical Education (ACGME) to allow data sharing, which will help CAST in its role of accrediting programs. A CAST process that partners with the ACGME for accreditation of fellowship programs, and with the ABNS for subspecialty certification of neurosurgeons, is a great accomplishment for our specialty and for patients with neurocritical care needs.

frogLeapfrog Group Recognition
Finally, The Leapfrog Group now recognizes the CAST process as equivalent to the United Council for Neurologic Subspecialties (UCNS) process for accrediting neurocritical care fellowships and certifying neurointensivists. On May 15, 2015, the Leapfrog Group updated its “Fact Sheet: ICU Physician Staffing” to define neurointensivists as one of the following:

  1. Board-certified physicians who are additionally certified in the subspecialty of Neurocritical Care Medicine. Certification in Neurocritical Care Medicine is awarded by the United Council for Neurologic Subspecialties (UCNS) or through completion of the Society of Neurological Surgeon’s CAST fellowship, with subsequent passage of the associated ABNS exam.
  2. Physicians board-certified in their specialty who have:
  • completed the CAST fellowship prior to the availability of the associated ABNS exam; and
  • provided at least six weeks of full-time ICU care annually.

Because of the work of organized neurosurgery, neurocritical care — an important and integral part of neurosurgery — will remain a field open to present and future generations of neurosurgeons. This is beneficial for neurosurgeons and neurosurgical patients alike.

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AANS Annual Meeting Spotlight: Peyton Manning Tosses Leadership TD

benzilGuest Post from Deborah L. Benzil, MD, FACS, FAANS
Vice President, AANS
Chair, AANS/CNS Communications and Public Relations Committee
MKMG
Columbia University Medical Center
Mt Kisco, New York

When I was young, I would ride my bike across town to the Baltimore Colts training camp. Watching Johnny Unitas (the best quarterback of his generation) work was inspiring and taught me important lessons in leadership. Most memorable was the work I saw with Raymond Berry, tossing him endless passes as the light was fading. Berry would plead to be done, noting the fading light made catching the intentionally off target passes nearly impossible to catch. Nonetheless Unitas continued on as he was preparing for the worst at game time, when stress would be high and success hinged on the preparation. Johnny Unitas was revered by his teammates for his hard work, his sacrifice and that he knew how to get the best from each of them. The benefit for me was the joy of seeing them win more often than not.

ft2

Peyton Manning addressing 2015 Annual Meeting AANS

Peyton Manning (arguably the best quarterback of this generation) spoke during the Opening Ceremonies of the 83rd AANS Annual Scientific Meeting and put into words the concepts that Johnny Unitas taught me decades earlier about leadership, teamwork, and preparation. It confirmed my belief that my youthful involvement in, and dedication to, football had laid an important foundation for my career in neurosurgery. Peyton kept the audience transfixed first with humor (noting the disappointment he knew his mother suffered when he hosted Saturday Night Live) and then with cogent concepts.

“Decision making is the currency of every profession,” he stated, noting, however, that in neurosurgery the ramifications are different than in his profession. He also told the audience, “Small decisions are the foundations of the next ones; anyone can become the game changer.” Poignantly, he noted that both fans and patients want the unattainable, a perfect performance every time with the past too easily forgotten by the immediate actions and outcomes.

Then he asked:

  • What are your game changers?
  • What does it take to make a difference?
  • Can you thrive on discomfort and not rehash the old?
  • Will you respond to the constant flux that requires constant adjustment?

His insights into how to approach these challenges included:

  • Intense preparation is essential;
  • Creativity drives solutions;
  • Everyone needs an honest coach (mentor) who will provide a different perspective;
  • Be determined to keep raising the bar; and
  • Instill trust in others to bring out the best.
Gino Marchetti and author 1964

Gino Marchetti and author 1964

Peyton concluded by again asking of us, “How do we learn to move the chains down the field?” Pulling all his concepts together he suggested that in football as well as neurosurgery, success comes to the master observers, an enormous source of power and creativity. This should be augmented by setting personal goals that contribute to organizational success because moving forward together is the only way to progress. Clearly, Peyton has the assurance and swagger of a winner, but always appreciates the need for team. He left the stage to a standing ovation after just one last inspirational concept: Success requires that we can rapidly get back to zero after experiencing a problem or set back.

On the most personal level, I again thank football for bringing me neurosurgical inspiration in the unlikely guise of Johnny Unitas and Peyton Manning.

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83rd AANS Annual Scientific Meeting Spotlight: Health Reform Update – James C. Capretta

Photo_BekelisGuest post from Kimon Bekelis, MD
Neurosurgical Resident, Dartmouth-Hitchcock Medical Center

The passage of the Affordable Care Act (ACA) has led to sweeping changes in the United States healthcare system, yet many questions about its implementation remain. Fortunately for neurosurgeons, during the 83rd AANS Annual Scientific Meeting held in May 2015, James C. Capretta, a senior fellow at the Ethics and Public Policy Center and a visiting fellow at the American Enterprise Institute, was one of the featured speakers who delivered an impassioned speech expressing his current view of the status of the ACA. He covered three areas in his talk:

Drawbacks of the ACA

Mr. Capretta suggested that the ACA is unpopular with the public for the following reasons:

  • Millions have seen increased health insurance premiums;
  • Millions have been forced out of their insurance plans;
  • Many have had to leave doctors that they liked (which they were told they could keep);
  • Medicare payments have been reduced; and
  • Taxes have been raised to pay for a massive new entitlement program.

capMr. Capretta further contended that healthcare reform has largely ignored the poor. He noted that the healthcare safety net has far too many holes because the ACA was built on a flawed system of health insurance. Lower income families, especially those enrolled in Medicaid, have a difficult time finding doctors who will accept their coverage. About one-third of physicians refuse to see new Medicaid patients, and referrals to specialists are especially difficult. In Washington State, for example, primary care physicians had 75 percent more problems obtaining a specialty referral for Medicaid patients than for those with commercial coverage.

Lastly, Mr. Capretta pointed out the ongoing dysfunction and inaccuracies of the ACA website, which he claims continues to cost U.S. taxpayers a significant amount of money. In his analysis, despite the claims and costs, the ACA has increased insurance coverage for Americans by a mere five percent.

The outstanding legal case against the ACA (King v. Burwell)

King v. Burwell is the case, now on the Supreme Court’s docket, contesting the legality of the federal government subsidizing insurance premiums for individuals in states that chose to utilize the federal insurance exchanges, rather than opting to build their own state-based exchange. A decision against the government’s provision of the subsidies would undermine the law in the 37 affected states and, in the process, disrupt insurance for millions of people who signed up for coverage on the assumption that the subsidies would be available.

ACAMr. Capretta speculated that there is a high possibility the Supreme Court will rule against these federal subsidies. He believes if the administration loses the case, President Obama will denounce the ruling as ideological and demand that Congress fix it, with no strings attached. He also estimated that the administration would develop a workaround for the states, allowing them to designate and use the federal exchange as if it had been built by the states. This would give administration officials a justification to continue paying federal subsidies in the states agreeing to the workaround, even if it were legally questionable. However, Mr. Capretta sees this case as one of the last opportunities for re-directing healthcare policy and replacing the ACA.

The potential for viable replacement of the ACA (Burr-Coburn-Hatch proposal)

Mr. Capretta was careful to point out that America’s healthcare system has significant strengths that must not be overlooked. Most notable is an openness to medical innovation, less centrally planned systems, and a network of clinics and hospitals capable of offering the most advanced care found anywhere in the world. The vast majority of Americans (almost 80 percent) have ready access to this high level of care through third-party insurance arrangements through coverage from their employers or federal programs like Medicare and Medicaid. Another 10 percent have individually purchased coverage. However, in his opinion the rising cost of healthcare necessitates a new system to replace the ACA.

Mr. Capretta claimed that significant progress has been made in developing a practical and workable alternative to ACA. For example, in January 2014, Sens. Richard Burr (R-N.C.); Tom Coburn, MD (R-Okla.); and Orrin Hatch (R-Utah) introduced a plan called the, “Patient Choice, Affordability, Responsibility, and Empowerment Act,” to replace the ACA. Listed below are key features in the proposal which were deemed as a credible alternative to the ACA:

  • A commitment to market-driven healthcare;
  • Retention of employer-based coverage;
  • Continuous coverage protection; and
  • Better healthcare for the poor.

Although, it’s unlikely that this plan will be passed into law, Mr. Capretta believes that it’s a good basis for discussion and future attempts to replace the ACA.

Within a days, the Supreme Court will announce a decision in the King v. Burwell case. Regardless of what the court ultimately decides, it will be interesting to watch how the next chapter of the ACA will unfold.

Posted in Access to Care, Coding and Reimbursement, Congress, Guest Post, Health, Health Reform, Healthcare Costs, Medicaid, Medical Innovation, Medicare | Tagged , , , , , , , , , , |